Patient-Centered Techniques for Succeeding with Diabetes

Transcription

1 PRACTICE IMPROVEMENT GUIDE Patient-Centered Techniques for Succeeding with Diabetes What is it that high-performing patientcentered medical homes do to achieve good outcomes with their diabetic patients? Discern Health asked that question of five primary care practices in a statewide multi-payer patient-centered medical home program in Maryland. Diabetic outcome data from the five practices ranked highly among the 52 practices between 2011 and This tool summarizes techniques that those successful practices used. All of the five practices were NCQArecognized as patient-centered medical homes (PCMHs) as of In-depth interviews with the staff of each practice showed that they all went beyond NCQA PCMH standards to implement patient-centered care in depth. The six areas described in this Guide summarize the cultural characteristics and the techniques they used, including: The key concept at work in each subject area The specific actions to which practices attribute their success in diabetes care. If you would like help in transforming your practice to a patient-centered medical home, consider local resources. There are many active programs now your state, your medical association, or one of your payers may offer assistance and possibly incentives. GLA-5544 Funded by Sanofi US 1

2 1 Follow-up and Outreach Key concept: Be systematic and diligent about ongoing care for diabetics. Consistent follow-up helps prevent emergencies and poor outcomes. Set follow-up times. Decide on each patient s need for follow-up based on time since diagnosis and self-management ability although in most cases practices follow up every 3 months, some patients need re-checks more or less frequently. After the first diagnosis of diabetes, schedule sooner follow-up on the initial care plan. On the first visit, the goal may be just to help the patient acknowledge the diabetes. Successful practices used one-month follow-up or sooner. When there has been a change in medication or any concern about the patient being able to follow a care plan, check in with the patient by phone or secure message 2-4 weeks after the appointment. Don t wait 3 months to find out the patient has not been taking medication. For patients who consistently manage their condition well as shown by clinical indicators, consider longer intervals between follow-ups, such as six months. Use your system consistently. Track patients and promote re-checks based on your office s processes here are two options for tracking: 2 Use appointment schedules. Make the next appointment at the end of the current appointment. Walk the patient to the appointment desk. Make sure she leaves with an appointment card. Use the practice s system to confirm appointments nearer to the scheduled time. Follow up with any patient who misses a diabetes appointment; if the patient misses multiple appointments, determine whether barriers such as transportation or financial problems are at work, and whether you can help. Analyze your data. Contact the patient later for reminders or to schedule an appointment. Give the patient a reminder to make an appointment for follow-up at the prescribed interval. Query the system for diabetics who will be due for a follow-up visit; contact them to make appointments. Consider prescribing only the number of months of medication until the next recommended re-check.

3 Track your success. Note for each patient the preferred contact method, and measure your success in reaching patients through their preferred methods. Make appointments meaningful. Have blood drawn for lab tests days before each appointment. In pre-visit planning, make sure the lab results are available before the appointment. This allows the provider and patient to discuss issues and make decisions based on current data. 3

4 2 Customized Plans to Engage Each Patient Key concept: Develop a care plan with, not just for, the patient. No two people have the same level of understanding or the same ability to make lifestyle changes. Be a partner. Agree with the patient on a care plan, rather than dictating the plan. Particularly with a newly diagnosed diabetic, the patient may need to take small steps. Help patients overcome barriers. In re-checks, address any barriers the patient has encountered in following the care plan, and help the patient to get around the barriers or find another solution. This might require using medications with different dosing schedules, or prescribing exercise that fits the patient s lifestyle. Use proven techniques. Consider training in motivational interviewing for patient engagement, which usually involves the following: Listen to and reflect on their statements about their lives and how they plan to manage their care. Ask permission to tell them information. Confirm and agree on a plan. Get creative! An individual patient might need to exercise indoors, or to learn to cook appropriate meals, or to get family members involved. There may be a need to find food resources for very low-income patients. Work more with the tougher cases. For patients who have the hardest time controlling their conditions: 4 Make sure they understand the risks: kidney failure, amputation, heart attacks, shorter life expectancy. Involve your care manager (see the next section). Consider a referral to endocrinology or to behavioral health if depression is an issue. Consider involving a family member or friend of the patient s choosing. 3

5 3 Care Management Key concept: Identify and execute care management as an established office function, assigned to appropriate team members. Patients with chronic conditions often need more than simple appointments with one provider to stay on track. Choose the right care manager for your practice. There are many ways to do care management, and different types of personnel who can do it. The care manager(s) must be able to relate effectively to patients, and to understand the primary care environment and the patient s life. (See Get creative! in Section 2.) Consider carefully whom you choose. The care manager may be the medical assistant who works the registries, contacts patients who need follow-up appointments or who have a new medication, and reaches out to patients who are not in control. The care manager may be a specially trained nurse or diabetes educator who works with each newly diagnosed diabetic and with each difficult case. The care manager may maintain a caseload of high-acuity patients and may contact them frequently as needed or recommend visits. Send patients to outside programs carefully. Recognize that different types of programs may work for different patients. Programs that teach patients only to count calories or count carbohydrates may work for very motivated patients, but may not work well for patients who need a flexible or simpler approach. 5

6 4 Comprehensive and Coordinated Care Key concept: Patient-centered care engages the whole patient and takes comprehensive responsibility, even for care outside the primary care practice s walls. Use all opportunities. In regular health assessment visits as well as important diabetes appointments, consider all physical and behavioral issues and the impact they may have on chronic conditions such as diabetes. Carefully manage transitions. When a patient has been hospitalized or seen in the emergency room for any reason, follow up promptly. Consult with the treating provider if necessary, and reconcile multiple medication lists into one list the patient or caregiver understands. Include education on self-management. Ensure that you can provide basic diabetes education to the patient one-on-one, including the patient tracking blood sugar or other metrics. Monitor specialists. Set agreements with specialists that clarify responsibilities; ensure that you get prompt feedback from any referrals you make, and that you use the feedback in planning care with the patient. For patients that you co-manage with a specialist, ensure that you exchange information regularly and that you together provide comprehensive care for the patient. Integrate behavioral health. Since behavioral health is often hard to locate for patients, and since depression and diabetes are such frequent comorbidities, consider all possible resources. These might include inviting a behavioral health provider to see patients in your office, referring to a public mental health clinic, or using a telemedicine resource. 6 5

7 5 Full Use of Information Technology Key concept: The primary care team effectively uses all the capabilities of its information technology to quickly identify patient needs at both the individual and the population levels. Use all the bells and whistles. Use the EMR s decision support function to prompt patient assessments and recommendations. Use the communications functions to send messages to other providers or to the patients. Use the registry and reporting capabilities to identify patients needing follow-up. Use care plan templates that support setting goals in partnership with patients. Provide the patient with a summary of each visit, the care plan you have developed together and, as appropriate, tools to help the patient monitor his/her condition; this might include regular mobile communications. Use the quality reporting capability to measure your progress in improving outcomes. Train and depend on a super user. Even if you are part of a larger health care system, identify one or more EMR experts within your office to keep up with upgrades, short cuts, and system changes, and to be a resource for other staff members. Inter-operate. If available, use (and maximize the use of) data from a health information exchange or from a health system EMR to monitor ER visits, hospitalizations of patients, and visits to other health system providers (such as specialists). Promote direct and prompt electronic communication with specialists. 7

8 6 TLC: Teamwork, Leadership, and Communication Key concept: High-functioning primary care teams are well-integrated. They fully activate team members of all staffing levels. Exert effective leadership. Build a culture that respects each team member s contributions to patient care, whether or not specific team members provide direct patient care. Take the time to identify the capabilities of all team members, both in terms of technical skill and in ability to effectively counsel patients. Train, check, and re-train. Educate staff upon hire on relevant electronic systems, care protocols, and common nomenclature to assure that all staff are speaking the same language. Regularly evaluate whether staff are functioning to the top of their license and adjust duties as necessary based on changing staffing needs. Communicate. Use regular meetings to consider and improve how the practice functions, and use daily huddles to plan for patients appointments. For an in-depth report of the project, and the findings that produced these patientcentered techniques, the entire report from Discern is available at: delivery-of-care/pcmh/2014-pcmh-report. 8